Ethics: Risk management is the name of the game Doug Taylor ­ 2005 Ethical issues facing counsellors is on the rise. In Queensland, the Christian Counsellors’ Association (CCAQ) has had to deal with four ethical issues over the past three years in its entire fifteen­year history. Since ethical complaints leveled at counsellors are becoming more common, it is essential that counsellors be alert to possible ethical breaches if they wish to avoid ethical or legal consequences. In reality, can counsellors afford not to be informed and aware of unethical possibilities? In our litigious age, the answer is a big fat NO. Counsellors, who choose not to be informed ethically, are walking on the edge of a cliff leading to unprofessional conduct or malpractice. Every counsellor faces having to make difficult ethical decisions on almost a daily basis. How they make those decisions primarily revolve around three essential measures. These measure include a counsellor’s personal values, awareness of ethical principles, and what personal moral characteristics he or she holds to. As a rule, Counselling Associations operate under a Code of Ethics or Ethical Principles (The Christian Counsellors Association of Australia [CCAA] is no exception). These ethical guidelines are designed to assist practitioners by guiding and directing their behavior as they relate to their clients. In assessing the criteria surrounding values, principles and moral qualities, it is first pertinent to clarify what is meant by “counsellor” or “practitioner” since the terms are often loosely used in the 21 st century as we hear about all types of counsellors. Generically, it refers to anyone endowed with the accountability of providing counselling and or psychotherapy services, including anyone assigned the role(s) of counsellor, psychotherapist, trainer, educator, supervisor, researcher, provider of counselling skills or manager of any of these services. The second important term to consider is “client.” In the counselling context, a client is a general definition referring to the receiver of any services provided by a counsellor. Importantly, the client may be an individual, couple, family, group, organization or other specifiable social unit. With these two definitions in mind it is helpful to note the implications regarding the measures for effective counselling as they relate first to personal values. Personal values: This measure includes the ability to be sensitive to and aware of how one’s personal values (what is considered important or of priority) as it impacts in counsellor – client relationship. These important values may include a commitment to:
· Recognizing a client’s individual rights and dignity;
· Guaranteeing the honesty of the counsellor ­ client relationship;
· Striving to maintain excellence in counselling by ensuring the quality of up­to­date professional knowledge and its application;
· Helping to ease the client’s personal misery and suffering;
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Promoting client self­identity that is meaningful to the person(s) concerned;
Enhancing self and client’s personal effectiveness in a wholistic manner (spiritually, physically, intellectually, emotionally, and socially)
Assisting in the growth of clients developing worthwhile relationships
Acknowledging and accepting the diversity of individual client human experience and culture
Ensuring fairness and quality of the kind of counselling and psychotherapy services provided. There is no doubt that these personal values impact on ethical principles. The values symbolize a significant way of articulating a commitment to ethical standards that are practical when expressed as a principle. Personal ethical principles: According to Corey (1996, p. 54­55), there are five basic principles that are reflected in codes that direct attention to important ethical responsibilities. Each principle is illustrated below with an example of good practice. A counsellor’s responsibility is to think about all the related conditions with as much care as is realistically possible and to be appropriately accountable for decisions made. These principles are: Beneficence: Beneficence is the process of a commitment to promoting the client’s well being. It is natural for clients who enter into a relationship with a counsellor to expect they will benefit from the service. This requires systematic monitoring of practice and outcomes by the best available means. One reason for counsellors having to undertake clinical supervision is to ensure this important principle is adhered to. Non­maleficence: Here we have a commitment to avoiding doing no harm to the client. It requires the counsellor to exercise care in staying clear of practices that may have a high risk of hurting someone, even unintentionally. This includes avoiding sexual, financial, incompetence, emotional or any other form of client exploitation. Autonomy: This principle is about respect for the client’s right to be self­governing. It is based on the belief that clients have freedom of thought and choice. The principle of autonomy opposes the manipulation of clients against their will, even for beneficial social ends. Counsellors are encouraged to help clients think clearly and personally weigh up the pay­offs or downside of their actions.
Justice: The principle of justice is about fair and equal treatment of all clients, and the provision of adequate services. The principle requires being just and respecting individual human rights and dignity regardless of age, race, gender, ethnicity, cultural background, disability socio­economic status, lifestyle orientation or religion. It involves taking into account any legal requirements and responsibilities, and remaining aware of potential conflicts between legal and ethical obligations. Fidelity: Fidelity as a principle asks counsellors to honour the trust placed in them as practitioners. This principle involves being careful not to deceive or exploit clients. It requires regarding confidentiality as a responsibility starting with the client’s trust. The principle also limits any disclosure of confidential data about clients to further the purposes for which it was originally disclosed. Self­respect: The British standards rightly include an additional principle relevant to counsellors, and form the basis for prevention of burnout and self­preservation of counsellors. This principle of self­care fosters the counsellor’s self­knowledge and care for self. It means that counsellors appropriately apply all the above principles as entitlements for self. Including seeking clinical supervision, therapy, and other training opportunities for personal development as required. The principle supports the notion of active commitment to growth activities and relationships that are independent of relationships in counselling or psychotherapy. A counsellor’s values and adherence to ethical principles are often determined by that counsellor’s personal moral characteristics as they are reflected in everyday behaviour. Personal moral characteristics: The counsellor’s personal moral characteristics are of extreme importance to counsellor – client relationships. Some of these characteristics could be seen as describing basic counselling skills or standards. Thus, it is essential that these personal qualities are deeply rooted in the individual counsellor, and progress out of personal commitment rather than the obligation of an external authority or abilities. Personal characteristics to which counsellors are urged to aspire include: Personal wholeness: the capacity to demonstrate balance in the areas necessary to show growth and personal development. The vital features of this balance include: physical (taking care of one’s body), emotional (being aware of personal emotions, the ability to manage personal emotions and others emotions), cognitive (avoiding thinking errors and maintaining appropriate rational perspectives), social (the ability to relate with others equally and respectfully, respecting individual rights), and spiritually (having a sense of recognising there are things bigger than self and with a purpose and connection with God). If these are demonstrated in the personal life of Jesus – Luke 2:52, why not us?
Empathy: the ability to communicate understanding of another person’s experience from that person’s perspective. This means having the capacity to step into another’s shoes. Biblically, one would say this is “compassion.” Literally, this means to feel with another person what they feel. Jesus is a wonderful example of this principle, when he became a human, moving from his position as God to that of man Phil.2:5­8. He knows what the human experience is like Heb.2:17; and Heb. 4:15. Acceptance: or agape love is the quality of accepting another without judging them; as a person is essential for counsellors to engage ethically with another person in pain Rom. 5:8. Congruence: Sincerity or genuineness, a personal commitment to consistency between what is professed and what is done. Integrity is a moral principle that fits aptly with the moral feature of empathy. This suggests that there needs to be a commitment to being moral in dealing with others, personal straightforwardness, honesty and coherence. He is the truth John 14:6. He is the personification of vulnerability and openness. Non­possessive warmth: involves respectfully demonstrating kindness, warmth and understanding by showing appropriate esteem to others and their appreciation of themselves. This characteristic works with resilience, an essential quality enabling one to have the capacity to work with the client’s concerns without being personally diminished. This feature requires the ability to recognise one’s boundaries. Moreover, just like Jesus, counsellors need to know when to rest Mark 6:31. Humility: another feature of Jesus’ life Matt. 11:29. An unassuming nature is the skill of truthfully acknowledging one’s own strengths and weaknesses, vital to ethical behaviour. Competence: involves the effective deployment of the skills and knowledge needed to do what is required. Paul said of the Romans that he was convinced that their motives and abilities were satisfactory in wanting to help and instruct others – Rom.15:4. Fairness, compassion and commitment are other essential moral qualities that require the consistent application of appropriate criteria to make informed decisions and take appropriate action. The Pharisee’s were condemned for lacking these vital moral characteristics – Matt. 23:23f. Wisdom as a moral characteristic is the possession of sound judgement that informs practice recognising that it is the way you live and not the way you talk that counts. God’s wisdom begins with a holy life – Jas.3: 14­17. Finally, Courage, the capacity to act in spite of known fears, risks and uncertainty is needed as a moral feature for counsellors. These features of personal values, ethical principles and personal moral characteristics need to alert counsellors to the complexity of our current society. Dealing with legal, gender, ethical, environmental, and multi­cultural issues means that counsellors must confront potential problems before they arise. A good question to ask is, “What can I do to improve my counselling practice?" Risk management is the name of the game. Anticipating potential risks is an effective way of avoiding ethical hazards. Ethical dilemmas have a tendency to sneak up on you. The best defence is an offence.
The APA’s Monitor consulted with some of psychology's ethical specialists to discover how psychologists can prevent common ethical dilemmas. Here's an adapted version of that advice that would be considered most effective when counsellors are practising appropriate personal values, principles and have moral standards. These obstacles to be aware of include: 1. Understanding multiple relationships: According to Ethical Principles or Codes, counsellors should avoid developing or maintaining relationships that could reasonably impair their professional performance, or could exploit or harm the other party. This is the issue of dual relationships. Avoiding dual relationships is not always possible however. This conundrum is more of a reality in the church community where the counsellor may also be the pastor and a personal friend. How does one evaluate the best possible action? APA Ethics Committee member Michael Gottlieb, PhD, suggests in a Psychotherapy (Vol. 30, No. 1) article that psychologists think about three factors: Power. How much of a power differential is there between the psychologist and the other person? Duration. Will it be brief contact or will it be continuous or episodic contact over a long time? Termination. Has the therapeutic relationship been permanently terminated, and does the client understand that as well? Consistently there is one type of duel relationship that is never appropriate. Sexual relationships with current clients are never permitted. 2. Protecting confidentiality Counsellors need to balance disclosure to varieties of people (employers, spouses, school administrators, insurance companies and others) with their ethical obligation to protect their client’s confidentiality. While such requests may occasionally be well intentioned, they conceal many dangers. Important questions to consider include: "Is there a law that authorizes the disclosure? Is there a law that sanctions me to disclose? Has my client consented to the disclosure?'" To help prevent confidentiality problems, counsellors must:
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3. Discuss the limits of confidentiality.
Ensure the safe storage of confidential records as required by the Privacy Act.
Know federal and state laws regarding confidentiality.
Obey mandatory reporting laws as in the case of child sexual abuse. Respecting individual's autonomy
Counsellors must provide the opportunity for clients to give their informed consent right at the start before counselling takes place. It is prudent to discuss:
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Limits of confidentiality, such as mandatory reporting.
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The nature and extent of the counsellor’s privacy policy.
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The counsellor's expertise, experience and limitations.
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The estimated length of therapy.
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Alternative treatment or service approaches.
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The counsellor's fees and / or billing practices.
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Whom to contact in case of emergency.
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The client's right to terminate sessions if necessary. 4. Knowing supervisory responsibilities Counsellors need to be aware they may be responsible for the actions of junior or peer colleagues who work under their supervision, such as interns or administrative personnel. That requires counsellors to frequently assess their supervisee’s competence. 5. Identifying what’s expected of them and who the client is: Counsellors need to understand whom they were hired to help and what is expected of them. Dilemmas crop up in a variety of settings:
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In couple counselling – the client is the couple and not the individual. However, the counsellor cannot decide for them if one wants the marriage to work and the other doesn’t.
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In legal or court issues, when it's not clear whether the counsellor is serving as an expert witness or advocate for one side.
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Third party issues such as when counsellors provide therapy to a person or entity at the request of a third party, such as a parent requesting therapy for their child or a government department requesting an evaluation of a person. Suggestions for avoiding role­related dilemmas, include:
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Know who your client is and what your role is
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Recognize your confidentiality limits 6. Noting, recording, and documenting: Recording specific descriptive documentation can be a counsellor’s best friend if facing ethical or legal charges. Suggestions for documenting include:
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Relevant history and risk factors.
Dates of service and fees.
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7. Assessments, treatment plans, supervision consultation, testing reports, and progress notes.
Informed­consent forms.
Pertinent telephone calls and out­of­office contacts.
Follow­up efforts if clients fail to return. Practising within limits of expertise: Every counsellor should be aware that they are obligated by the Code of Ethics to counsel within their limitations and competency. But sometimes trouble arises when, for example, counsellors are involved in emerging areas where there are no clear principles. A way to help prevent this from occurring is to:
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Stay in touch with the profession through conferences,
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Maintain continuing professional education,
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Consult with supervisors and colleagues, and
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Read professional counselling and psychology journals. 8. Knowing when to initiate closure and its potential pitfalls: The CCAA frequently receives calls from counsellors who want to terminate counselling with a client, but are concerned since they fear they may be giving up on the client. However, counsellors can discontinue treatment when clients:
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Aren't benefiting from counselling.
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May be harmed by the counselling.
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No longer need counselling.
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Threaten the counsellor, themselves or others. It is best if counsellors want closure with clients to involve the client in the process and provide some form of pre­termination counselling and / or suggest alternative service providers if necessary. 9. Sticking with the facts: If required to provide a professional opinion or report, recognise your limitations and base your assessment only on the facts and available data. It is best to keep in mind what you know, what you don't know, and what your sources of information have been. 10. Being honest in charging client fees: Truthfulness in charging or billing clients is vital. Creative bookkeeping can get a counsellor into serious trouble. To avoid such ethical problems, counsellors should:
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Charge only for services provided.
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Only list the dates the client was seen unless a “no show” policy is evident.
Call it as you see it.
Discuss fee structures before counselling begins.
Be meticulous about collecting fees.
Exercise vigilance in pursuing delinquent accounts.
Take scrupulous care of your paperwork. When all of these ethical principles are considered, putting them into some practical perspective is imperative. That is, how they translate into what counsellors do in their every day practice. Facing difficult decisions about what is the best way to handle an ethical issue isn’t always obvious. Many times there are no easy answers. Some guidelines that counsellors may need to note when faced with ethical decisions include:
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Clearly identify and clarify what the problem or dilemma is: Assess all the pertinent facts and data and attempt to establish whether the problem is moral, legal or ethical.
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Know your material: This may require you to regularly read through your respective code of ethics on a monthly basis. It also means that every counsellor should be aware of what state and federal laws may apply to the context of their work. Recognizing that in Australia these state laws can vary from state to state.
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Trust your intuition If a situation does not feel right or if you find yourself at an ethical stalemate, see it as a warning that something is not right. It is best if one has ethical questions to be proactive and search for answers and try and reach a conclusion to the situation.
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Consult widely with others It is best to consult with your supervisor or fellow therapists at the first sign of a possible ethical gridlock, continuing to seek advice until the matter is decided. Talk with a representative from your professional association, or seek legal advice. It is best to consult widely to gain a variety of perspectives.
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Brainstorm and catalogue various possible courses of action When you are consulting, explore as many possible options as possible and itemize the consequences of the various options, keeping in mind the six ethical principles that govern this area, namely: autonomy, non­maleficence, beneficence, justice, fidelity and self­respect.
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Confront issues head on Avoid covering issues up. Anticipate potential issues and if unsure, consult widely upfront with others. It is not possible to foresee every likely ethical hazard, but by sharing with others, one can learn from their experience and gain possible different
perspectives. The point is, face the issues early, rather than waiting until they bite you when it’s too late.
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Dig deeper Ethics is more than a do and don't list. Developing self­awareness of your own psychological self along with external accountability can be an effective way to alleviate many of the possible dangers with making ethical decisions. Conclusion The need to work ethically means that counsellors will without doubt stumble upon circumstances where there are challenging requirements. If so, it is tempting to draw back from all ethical examination in what may seem to be unavoidable ethical anxiety. Becoming aware of ethical issues is a way confronting the diversity of ethical features that a counsellor may engage in his or her practice and offers a means of understanding ethics that may prove helpful in the future. No comprehensive account of ethics can completely lessen the complexity of what may be required to make professional ethical decisions in conditions that are continually evolving and fraught with questions. However, counsellors need to be alert to this challenging and changing subject and minimize possible exposure to ethical and legal problems by being the best counsellors you can be. References: Barker, P. and Baldwin, S. (eds). (1991). Ethical issues in mental health. Melbourne, VIC: Chapman and Hall. Christian Counsellors’ Association of Australia Statement of Ethics. (1998). Melbourne, VIC: Corey, G. (1996). Theory and practice of counseling and psychotherapy, (5 th edition). New York, NY: Brooks / Cole Publishing Company. Ethical Guidelines. (1999). Melbourne, VIC: Psychotherapy and Counselling Federation of Australia. Gottlieb, M. (1999) Psychotherapy (Vol. 30, No. 1) http://www.bacp.co.uk/ Retrieved July 30, 2003. Roodenburg, J. (1997). Ethical dilemmas for church based mental health and allied services. Cairns, QLD: Paper presented at the Christianity and Psychological Symposium, 32 nd Annual Conference. Sanders, R. (ed). (1997). Christian Counselling ethics: A Handbook for therapists, pastors, and counsellors. Downers Grove, IL: Intervarsity Press. Smith, D. (2003). 10 ways practitioners can avoid frequent ethical pitfalls Boost your ethical know­ how with these practical tips on avoiding common ethical quandaries. Monitor on Psychology, American Psychological Association.